Suicide Mortality During the Perinatal Period

Key Points Question What circumstances are associated with perinatal (ie, pregnant and postpartum) suicide, and how do they vary across the perinatal period? Findings In this cross-sectional study using data from the National Violent Death Reporting System, perinatal decedents were more likely to experience intimate partner problems (IPPs), depressed mood, substance abuse, physical health problems, and recent bereavement compared with matched nonperinatal decedents. Qualitative analysis identified precipitating mental health circumstances, including postpartum depression. Meaning These findings highlight the need for policy making that targets mental health, substance use, and IPPs to mitigate perinatal suicide risk.


Introduction
Suicide during the perinatal period (eg, during pregnancy and Յ1 year post partum) is a leading cause of maternal mortality in the US, contributing to 8.4% of pregnancy-related deaths. 1,2A Centers for Disease Control and Prevention (CDC) report from 36 state maternal mortality review committees considered more than 80% of maternal deaths preventable, including 23% of deaths from mental health conditions, primarily suicide and overdoses related to substance use disorders. 2e US uses the World Health Organization (WHO) definition of maternal mortality as deaths of women while pregnant or within 42 days of pregnancy, from any cause related to, or aggravated by, the pregnancy or its management, but not from accidental or incidental causes. 3The WHO classification of deaths involving pregnancy and childbirth excludes suicides, as well as accidents and homicides, and deaths occurring within 43 to 365 days of delivery. 3The WHO definition thus underestimates the true burden of lives lost.Additionally, racial and ethnic disparities in maternal health-including pregnancy-related mortality-persist, 4 as do disparities in access to mental health services across screening, diagnosis, and treatment. 5 the context of the White House Blueprint for Addressing the Maternal Health Crisis, which aims to address maternal mental health and reduce preventable pregnancy-related deaths, 6 this study uses data from the National Violent Death Reporting System (NVDRS) to examine precipitating circumstances of suicide among pregnant, postpartum, and similarly aged nonpregnant women. 7e NVDRS is a CDC-funded, state-based surveillance system that collects data on violent deaths abstracted from investigative reports.The NVDRS is the largest collection of suicide data in the US and provides an opportunity for population-level mixed methods research.
Previous studies that have examined quantitative factors associated with pregnancy-related deaths [8][9][10][11] have reported that mental health problems, substance use disorders, and intimate partner problems (IPPs) preceded suicide and homicide in pregnancy.Limitations of the aforementioned studies include sole use of older quantitative data sources, which typically reflect a limited number of states, smaller sample sizes, or both.This cross-sectional observational and qualitative study had the following goals: (1) to identify characteristics more prevalent among perinatal suicide decedents compared with nonperinatal decedents, (2) to leverage quantitative and qualitative NVDRS data to explore circumstances that distinguish pregnancy and postpartum periods among perinatal decedents, and (3) to characterize key themes from circumstances among perinatal decedents.We also sought to illuminate underlying factors for perinatal suicide to inform targeted prevention strategies for this population.

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The NVDRS Restricted Access Database contains text narratives that are typically between 150 and 300 words and are written by NVDRS staff using coroner, medical examiner, and law enforcement reports, death certificates, suicide notes, and interviews with decedents' family and friends.
The University of Michigan Institutional Review Board deemed this study exempt from review and waived the need for informed consent due to the use of decedent data.We preregistered the study on the Open Science Framework 14 and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Exposures
According to the NVDRS pregnancy status variable, we created 2 comparisons among reproductiveaged individuals (aged 10-50 years).For the first comparison, we defined pregnant using the "pregnant at time of death" variable.We defined post partum by grouping the variables "not pregnant but pregnant within 42 days of death" and "not pregnant but pregnant within 43 days to 1 year before death."For the second comparison, we defined perinatal by combining the variables "pregnant" and "postpartum."Finally, we defined nonperinatal by grouping the variables "not pregnant, not otherwise specified" and "not pregnant within the last year."

Outcomes
Informed by the life-course theory of suicide, 15 we used 13 salient circumstance binary variables (yes vs no, not available, or unknown) derived from NVDRS code as outcomes.We further classified these variables into the following 6 groups: relationship problems (intimate partner, family relationship, or argument), mental illness (depression diagnosis, Ն2 diagnoses, depressed mood, current treatment for mental illness, or history of treatment for mental illness), substance problems (alcohol problem or substance or other abuse), physical health problems, job or financial problems, and death of a friend and family member.eAppendix 1 in Supplement 1 provides additional details for each circumstance.

Covariates
Covariates included age (grouped by quartile; 10-23, 24-28, 29-34, or 35-50 years for pregnant vs postpartum; and 10-27, 28-37, 38-44, or 45-50 years for nonperinatal vs perinatal), race and ethnicity, educational attainment (grade 12 or less, high school diploma or GED, some college or college graduate or above, or unknown), and marital status (single or never married, married or domestic partnership, or divorced, separated, or widowed).We included race and ethnicity to describe differences in suicide rates by racial and ethnic group as well as racial disparities in perinatal outcomes.These data were defined by the NVDRS and included Black, Hispanic or Latino, White, or other race or ethnicity (ie, American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander, or unspecified race or ethnicity).We included 3 binary (yes vs no) variables related to death circumstances: injury location (ie, injured at home), autopsy (ie, whether the decedent underwent an autopsy), and in the labor force.

Quantitative Analysis
We estimated odds ratios (ORs) with 95% CIs to compare sociodemographic characteristics in 2 ways: pregnant vs postpartum and perinatal vs nonperinatal.Substantial differences in demographic characteristics between the 2 comparison groups could bias the effect of pregnancy status on circumstances.Therefore, we estimated propensity scores based on race and ethnicity, educational attainment, age group, and state, using optimal full matching to generate matched datasets for the 2 comparison groups, respectively (eMethods in Supplement 1 (perinatal vs nonpregnant and postpartum vs pregnant) and circumstances surrounding suicide. 16e models controlled for the aforementioned sociodemographic characteristics.P < .05(2-tailed)   was considered statistically significant.We ran 2 post hoc sensitivity analyses to examine the robustness of our findings.First, we examined the association between cause of death and pregnancy status.Then we repeated the matching process and logistic regressions analyses, excluding undetermined deaths.

Qualitative Measures and Analysis
Using thematic analysis, we employed an iterative, multistep approach to analyze qualitative narrative data based on grounded theory and open coding procedures (eAppendices 2 and 3 in Supplement 1).

Cohort Characteristics
Figure 1 describes the sample selection and study cohorts, and the eFigure in Supplement 1 describes the study design.

Quantitative Findings
Compared with nonperinatal decedents, perinatal decedents were younger, were less likely to be White, had lower educational attainment, and were more likely to be married (Table 1).Among the perinatal sample, postpartum decedents were younger and were more likely to be married compared with pregnant decedents.
Compared with pregnant decedents, postpartum decedents had higher odds of having had a  2B).eTable 1 in Supplement 1 presents data related to Figure 2.
In a post hoc sensitivity analyses, cause of death (suicide vs undetermined death) was not associated with pregnancy status (eTable 2 in Supplement 1).In the repeated regression analyses, after excluding undetermined deaths, key findings were substantially unchanged from the main analysis.Although the associations for 3 specific circumstances (eg, bereavement, substance abuse, and physical health) became insignificant, the direction of the association remained unchanged (eTable 3 in Supplement 1).

Qualitative Findings
Table 2 summarizes key findings from 5 most common themes from the qualitative analysis, highlighting challenges related to mental health and substance use in the perinatal sample.Table 3 presents the frequency of all themes and subthemes for pregnant and postpartum groups.For

Discussion
In this study, we investigated factors occurring with perinatal suicide to inform policy and prevention strategies.The US has the highest maternal mortality rate among developed countries, with striking racial and ethnic disparities, 4 although nearly all of these maternal deaths remain preventable. 2erefore, improved targeting of policy and prevention strategies has the potential to enhance outcomes and to begin to address this crisis.
Primary findings from this study suggest that perinatal decedents were more likely to have experienced circumstances such as IPPs, depressed mood, substance abuse, physical health, and recent bereavement relative to nonperinatal decedents.Qualitative analysis of narrative themes among perinatal decedents emphasized the importance of mental health.Conflict with an intimate partner represented another common finding in the qualitative analysis.Finally, quantitative and qualitative analyses illustrated information gaps bridged by using both types of NVDRS data and provided context for understanding how risk factors for suicide (eg, poor mental health) varied over the perinatal period.
Our qualitative analysis contained more nuanced information related to the perinatal circumstances than quantitative analysis alone.For example, qualitative analysis identified patients who experienced postpartum depression, miscarriage, and abortion.The NVDRS could integrate such qualitative codes into the coding manual to improve contextual information related to   • The theme and subthemes characterize decedent substance use and abuse • A total of 382 decedents (37.0%) were described to use or abuse illicit drugs • A total of 273 narratives (26.5%) indicated prescription drug use, which included cases of misuse or abuse • For 14 decedents (1.3%), the narrative mentioned that the decedent obtained access to the drugs or medications from a family member or acquaintance • A total of 260 decedents (25.2%) were known to use or abuse alcohol • For 137 decedents (13.3%), the narrative mentioned that the decedent died of a drug overdose, but whether the overdose was intentional or unintentional was unclear • "D had a history of alcohol abuse and had previously been in rehab.D also had chronic pain from a herniated disk and was recently prescribed fentanyl patches.It was reported that D would abuse her prescription medications occasionally."pregnancy.This finding highlights the potential benefit of qualitative analysis alongside quantitative analysis.
We observed some demographic differences in suicidality from other literature.Previous research found that non-Hispanic Black pregnant women had the highest prevalence of suicidal ideation, suicide attempts, and nonsuicidal intentional self-harm. 23Compared with nonperinatal decedents, perinatal decedents were younger, were less likely to be White, had lower educational attainment, and were more likely to be married.We did not observe any statistically significant differences between postpartum and pregnant decedents.These findings suggest that clinicians and policy makers should work to address the needs of these vulnerable populations.
Although perinatal decedents in this study were more likely to be married than nonperinatal decedents, single and never-married individuals represented more than half of perinatal decedents.
Prior research found that unmarried pregnant women with lower educational attainment and lower income had a higher risk of intimate partner violence (IPV), 24 a risk factor for perinatal suicide, indicating that these individuals may also require support and follow-up.High marital satisfaction during pregnancy may protect against suicidal ideation, 25 and suicidal ideation occurs more commonly among unmarried pregnant women. 26Future research could explore interactions between risk factors for perinatal suicide and marital status.
In the present study, some circumstances overlapped between perinatal and postpartum decedents.For example, both were more likely than their comparison groups to experience mental healthrelated circumstances, such as depressed mood, substance abuse (perinatal), depression diagnosis, and current mental illness treatment or past mental illness treatment (post partum).In prior research, investigators found that mental health-related circumstances increased the risk of suicide or self-harm among perinatal individuals. 9,10,27,28Within this context, our study highlights the importance of perinatal mental health screening, including for suicidal ideation, 29 and clinical follow-up. 30 this study, the aforementioned themes of substance and alcohol abuse represented 2 dominant qualitative circumstances and are an area for further research to better understand circumstances of perinatal decedents with these conditions.Women with substance or alcohol use disorders are also more likely to experience depression and IPV, 31 presenting a complex picture of

Figure 2 .
Figure 2. Odds Ratios (ORs) of Circumstances Contributing to Suicide

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).After matching, we used 2 sets of

Table 1 .
Table2demonstrates that qualitative analysis offers complementary findings to quantitative analysis.In general, qualitative themes were largely concordant with quantitative NVDRS circumstances.However, qualitative themes yielded richer and more nuanced insights for Characteristics of Decedents (Nonperinatal, Pregnant, or Postpartum Within 1 Year), 2003 to 2021 a domain.For instance, for IPPs, content analysis gave further insight into the timing of the conflict (ie, recent or past) or argument (ie, within 48 hours prior) and further characterized the type of relationship conflict (ie, abuse [verbal, physical, or sexual] or divorce or breakup) compared with using solely quantitative analysis.Similarly, for mental health themes, qualitative analysis identified detailed challenges beyond diagnosis, such as experiencing postpartum depression (including relapse) and treatment nonadherence.Insights from qualitative analysis added more detailed and a Unless specified otherwise, data are presented as the No. (%) of decedents.Decedents with missing race and ethnicity, age, and marital status (10 in the perinatal group and 164 in the nonperinatal group) were removed from the analytic sample.bFordata presented as the No. (%) of decedents, values are expressed as OR (95% CI); for data presented as mean (SD), values are expressed as mean difference (95% CI).c Defined by the NVDRS and includes American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander, and unspecified race or ethnicity.dIncluded in the statistical testing for educational attainment.each

Table 2 .
Summary of Qualitative Findings for the 5 Most Common Themes Among Pregnant and Postpartum Decedents

Table 3 .
Qualitative Themes of Precipitating Circumstances From Coroner, Medical Examiner, and Law Enforcement Narratives for Perinatal Decedents (Suicides and Undetermined Deaths) a

Table 3 .
Qualitative Themes of Precipitating Circumstances From Coroner, Medical Examiner, and Law Enforcement Narratives for Perinatal Decedents (Suicides and Undetermined Deaths) a (continued) Supplemental Details of Circumstance Variables for Quantitative Analysis, Adapted From the National Violent Death Reporting System Coding Manual (Version 6.0) eMethods.Matching Process for the Quantitative Analysis eAppendix 2. Qualitative Codebook With Definitions Annotators Used to Determine Themes and Subthemes to Assign Cases eAppendix 3. Narrative Analysis Process eFigure.Cross-Sectional Observational Study and Qualitative Analysis Design eTable 1. Quantitative Predictors From Figure 2 eTable 2. Post Hoc Sensitivity Analysis: Association Between Cause of Death (Suicide vs Undetermined Death) and Pregnancy Status eTable 3. Post Hoc Sensitivity Analysis: Associations Between Salient Circumstances and Suicide (Odds Ratios)